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Record W4409413640 · doi:10.2147/clep.s504259

Extracting Cognitive Impairment Assessment Information From Unstructured Notes in Electronic Health Records Using Natural Language Processing Tools: Validation with Clinical Assessment Data

2025· article· en· W4409413640 on OpenAlex
Kuan‐Yuan Wang, Mufaddal Mahesri, John Novoa-Laurentiev, Lily G. Bessette, Cassandra York, Heidi Zakoul, Su Been Lee, Kerry Ngan, Zhou Li, Dae Hyun Kim, Kueiyu Joshua Lin

Why this work is in the frame

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aboutThe title or abstract carries a Canadian signal from the geographic lexicon.
no affNo Canadian affiliation: this work is invisible to an affiliation-only frame.
No Canadian affiliation. An affiliation-only frame, the usual design, would never have seen this work. It is one of the works that make the case for inverting the frame.

Bibliographic record

VenueClinical Epidemiology · 2025
Typearticle
Languageen
FieldComputer Science
TopicMachine Learning in Healthcare
Canadian institutionsnot available
FundersU.S. National Library of MedicineNational Institutes of Health
KeywordsHealth recordsMedicineCognitive impairmentCognitionUnstructured dataNatural language processingElectronic health recordData scienceInformation retrievalData miningComputer scienceArtificial intelligencePsychiatryBig dataHealth care

Abstract

fetched live from OpenAlex

Purpose: We aimed to develop a Natural Language Processing (NLP) algorithm to extract cognitive scores from electronic health records (EHR) data and compare them with cognitive function recorded by Centers for Medicare & Medicaid Services (CMS)-mandated clinical assessments in nursing homes and home health visits. Patients and Methods: We identified a cohort of Medicare beneficiaries who had either the Minimum Data Set (MDS) or Outcome and Assessment Information Set (OASIS) linked to EHR data from the Research Patient Data Registry (Mass General Brigham, Boston, MA) from 2010 to 2019. We applied an NLP approach to identify the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) scores from unstructured clinician notes in EHR. Using the NLP-extracted MoCA or MMSE scores from EHR, we compared mean differences of extracted MoCA or MMSE by cognition status determined by MDS (impaired vs intact cognition) and OASIS (severe impairment vs intact cognition) data, respectively. Results: Our study cohort had 7419 patients who had MDS (19.7%) or OASIS (80.3%) assessments, with a mean age of 80 (SD=7) years and 60% female. In EHR, the NLP algorithm extracted cognitive test scores with 97% accuracy (95% CI: 92-99%) for MoCA and 100% accuracy (95% CI: 84-100%) for MMSE. In MDS, the mean difference in extracted MoCA was -5.6 (95% CI: -8.7, -2.4, p=0.0008), and the mean difference in extracted MMSE was -7.9 (95% CI: -12.4, -3.5, p=0.0012). In OASIS, the mean difference in extracted MoCA and extracted MMSE was -4.8 (95% CI: -9.1, -0.6, p=0.0006) and -4.5 (95% CI: -9.5, -0.5, p=0.0182), respectively. Conclusion: We developed an NLP algorithm to accurately extract cognitive scores from unstructured EHR, and these extracted cognitive scores were well correlated with cognition function recorded in CMS-mandated clinical assessments. This could help researchers identify patients with various degrees of cognitive impairment in EHR-based research.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.

Full frame distilled prediction

Teacher imitation

Not calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.

metaresearch head score (Codex)0.022
metaresearch head score (Gemma)0.019
Version: codex-gemma-dda1882f352aValidation status: machine_predicted_unvalidated
Candidate categoriesMetaresearch, Research integrity
Consensus categoriesnone
DomainCandidate signal: none · Consensus signal: none
Study designCandidate signal: Observational · Consensus signal: none
GenreCandidate signal: Empirical · Consensus signal: none
Teacher disagreement score0.525
Threshold uncertainty score0.999

Codex and Gemma teacher scores by category

CategoryCodexGemma
Metaresearch0.0220.019
Meta-epidemiology (narrow)0.0000.000
Meta-epidemiology (broad)0.0010.000
Bibliometrics0.0000.001
Science and technology studies0.0000.000
Scholarly communication0.0000.002
Open science0.0010.001
Research integrity0.0000.003
Insufficient payload (model declined to judge)0.0000.000

Machine scores (provisional)

The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.

Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.

Opus teacher head0.192
GPT teacher head0.562
Teacher spread0.370 · how far apart the two teachers sit on this one work
Validation statusscore_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from it